21-22 Radiation Therapy Student Handbook

RADIATION THERAPY TECHNOLOGY STUDENT HANDBOOK Academic Year 2021-2022 SUNY Erie Community College City Campus 121 Ellicott Street Buffalo, NY 14203

The Radiation Therapy Technology Department of SUNY Erie Community College conducts a review of the program’s Mission Statement, Goals, Policies and Procedures annually.

Revised March 31, 2021

Table of Contents Introduction ............................................................................................................... 4 Certification Disclosure ............................................................................................... 5 Leadership and Faculty ............................................................................................... 6 Accreditation .............................................................................................................. 7 Program Affiliation Clinical Locations & Supervisors .................................................... 8 Mission Statement & Goals of the Radiation Therapy Program.................................... 9 Admission and Retention Requirements: Safety and Technical Skills ........................... 10-11 General Information- Nature of the Program .............................................................. 12 Program / Graduation Requirements .......................................................................... 13 SUNY ERIE Academic Standards and Policies ............................................................... 13 Course Syllabus/Attendance Policies: Class ................................................................. 14 Attendance Policies: Clinical ....................................................................................... 15-16 Trajecsys .................................................................................................................... 17-18 Program Probation/Termination/Remote proctoring .................................................. 19 Holidays, Snow days ................................................................................................... 20 Bereavement .............................................................................................................. 21 Student Emergencies .................................................................................................. 21 Moral Character/Social Media .................................................................................... 21-24 Plagiarism and Cheating.............................................................................................. 24 Advisory Council ......................................................................................................... 24 Pregnancy Policy/Acknowledgement of Pregnancy Counseling.................................... 24-26 (Disclosure and Declaration Withdrawal Forms) (ref 45-46) Special Lectures .......................................................................................................... 27 Parking, Transportation and Housing .......................................................................... 27 Misc Fees.................................................................................................................... 27 Confidentiality/Statement .......................................................................................... 27 Name Tags .................................................................................................................. 27 Radiation Badges and Reports .................................................................................... 27-28 Adverse Weather Conditions ...................................................................................... 28 Health and MRI Policy................................................................................................. 28-29

POLICIES, RULES AND REGULATIONS GOVERNING STUDENTS:

Radiation Therapy Program ........................................................................................ 29-30 Clinical Dress Codes/Hygiene ...................................................................................... 30-31 Smoking Policy ........................................................................................................... 31 Ethical Expectations .................................................................................................... 32-33 Policy on Health Records and Communicable Disease ................................................. 33-34 Program Standards ..................................................................................................... 34 Accreditation and Standards Agencies ........................................................................ 35 Competency Requirements ......................................................................................... 35-36 Grievance/Student Complaint Procedure (Due Process) .............................................. 36-39

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Diversity/Title IX......................................................................................................... 40 Cell Phone Policy ........................................................................................................ 41

PART II CONTENTS/TOPICS

Mandatory Treatment Procedures .............................................................................. 42-43 Mandatory Simulation Procedures .............................................................................. 43 Confidentiality Form ................................................................................................... 44 Pregnancy Disclosure (P-1) and Declaration Withdrawal (P-2) Forms ........................... 45-46 MRI Student Safety Screening Questionnaire (Example) .............................................. 47 Radiation Exposure Reporting Forms A and B .............................................................. 48-49 Handbook Review Verification (example).................................................................... 50

TRAJECSYS DOCUMENTATION

The following functions are tracked through the system:

Clinical Site Orientation Attendance Records (freshman, senior and summer) Clinical Evaluation instruments (treatment, exam room and simulation) Logs-Level of participation Pre-Treatment Patient Assessment Pre-Simulation Patient Assessment Treatment Competency Form Simulation Competency Form Clinical Instructor Evaluations MRI Screening Exit Survey Instructor Evaluation Handbook Acknowledgement

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INTRODUCTION

The Radiation Therapy Program at SUNY Erie Community College prepares professional students in the field of radiation therapy, a highly specialized branch of medicine that utilities ionizing radiation in the treatment of disease. The radiation therapist is a professional member of the Radiation Oncology team which includes physicians, physicists, dosimetrists, nurses, and social workers.

Through the combination of didactic and clinical education, the Program provides Radiation Therapy students with a strong foundation in oncological diseases, physics, patient care and clinical skills. Technical skills gained will allow students to utilize ionizing-radiation producing equipment in the treatment of cancer for both curative and palliative purposes. In addition to meeting the technical requirements, graduates will possess the knowledge and skills to provide the appropriate patient care and patient-centered communication to patients and their families experiencing the diagnosis and treatment of cancer.

The Radiation Therapy Program at SUNY Erie Community College is a FT 24-month competencybased education consisting of both a didactic and clinical curriculum. The Program has its own established and approved admission and graduation requirements and has primary responsibility for designing and implementing the education program, procedural guidelines and regulations deemed necessary to carry out the Program’s educational objectives. The Program is fully accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT).

Upon matriculation into the Radiation Therapy Program, each student agrees to be bound by the Code of Conduct, rules, policies, procedures and administrative regulations of SUNY Erie Community College and the Radiation Therapy Program, as they exist at the time of admission, and as they may be changed during the student’s continued enrollment. Students must be familiar with the policies and procedures of the Program as outlines in this handbook and are also required to familiarize themselves with all policies and procedures of SUNY Erie as published on the college Intranet. The Radiation Therapy Program reserves the right to update any information in the student handbook based on policy, curricular, or process revisions at any time during the academic year.

ACCREDITATION

SUNY Erie Radiation Therapy Program is accredited by the Joint Review Committee on Education in Radiologic Technology (JRCERT) and meets the requirements for national board certification. As a graduate of a JRCERT accredited program, students are eligible for national board certification through The American Registry of Radiologic Technologists (ARRT). Upon achieving national ARRT board certification, students are eligible for individual state licensure as required by each distinct state. (see Below)

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CERTIFICATION DISCLOSURE:

SUNY Erie Community College Radiation Therapy Technology curriculum and its program of study meets the educational requirements by the Board of Regents in New York State to award an Associate in Applied Science Degree (AAS) with a major in Radiation Therapy Technology.

Graduates are eligible to take the American Registry of Radiologic Technologists (ARRT) credentialing exam for certification as a Registered therapist and apply for Radiation Therapy licensure in New York. Other states may have different educational requirements for program completion and licensure requirements. SUNY Erie Radiation Therapy Program has not made a determination of whether the curriculum meets the educational requirements for licensure in states other than in New York. If seeking licensure in a state other than New York, please review the requirement of that American Registry of Radiologic Technologists. To search a particular State’s licensure information please visit:https://www.asrt.org/main/standards-andregulations/legislation-regulations-and-advocacy/individual-state-licensure

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SUNY Erie Community College Leadership and Faculty

William Reuter

Interim President

Douglas Scheidt

Provost and Executive Vice President of Academic Affairs

Adiam Tsegai

Vice Provost of Health Sciences

Dhiren K. Shah, M.D.

Medical Advisor (716) 844-5500

Jean Wood, MHA, MBA, CMD, RT(T)

Program Director Office: (716) 270-4726 Email: wood@ecc.edu

Clinical Coordinator Office: (716) 270-5129 Email: masonk@ecc.edu

Keith Mason

Program office hours are Monday through Friday, 8:00 AM to 4:00 PM (subject to change), not including college holidays. Program offices are located at 45 Oak street Room 147. Students are encouraged to schedule appointments with faculty in advance. Appointments can be arranged with the individual or through the appropriate Program staff.

Radiation Therapy Program Website

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This program is accredited by the New York State Department of Health and the Joint Review Committee on Education in Radiologic Technology.

The Joint Review Committee on Education in Radiologic Technology (JRCERT) 20 North Wacker Drive, Suite 2850 Chicago, Illinois 60606-3182 Phone: 312-704-5300 A Copy of Standards for an Accredited Educational Program in Radiologic Standards is available online at: www.jrcert.org and/or mail@jrcert.org American Society of Radiologic Technologist (ASRT) https://www.asrt.org/ The American Registry of Radiologic Technologist (ARRT) https://www.arrt.org/

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Program Affiliation Agreements Clinical Locations and Supervisors Cancer Care of WNY (CCWNY)

Address: 3085 Harlem Road, Cheektowaga, NY 14225 Clinical Supervisor: Heather Stoneman - (716) 844-5500

CCWNY Jamestown

Address: 117 Foote Avenue, Jamestown, NY 14701 Clinical Supervisor: Jay Rosa - (716) 704-4800

CCWNY Cambria

Address: 3850 Saunders Settlement, Suite 100, Cambria, NY 14132 Clinical Supervisor: Dena Vitello - (716) 898-2850

UPMC Erie

Address: 2500 West 12th Street, Erie, PA 16505 Clinical Supervisors: Jim Hovis/Sean Friedrich, Linacs - (814) 835-9715

Rochester General Hospital - Dept. of Radiation Therapy Address: 1425 Portland Avenue, Rochester, NY 14621 Clinical Supervisor: Nancy Miles - (585) 922-9444

Linden Oaks Medical

Address: 20 Hagen Drive, Suite 100, Rochester, NY 14625 Clinical Supervisor: Nancy Miles - (585) 922-9116

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Mission Statement The mission of the Radiation Therapy Technology Program is to provide a comprehensive education and emphasize excellence by incorporating extensive didactic learning, professional courses, and clinical experiences necessary to prepare students to: become entry-level radiation therapists, provide quality patient care, be active participants in the profession, and to pursue life-long learning.

Goals of the Radiation Therapy Technology Program Goal 1:

Students will be clinically competent.

Student Learning Outcomes: Students will simulate, plan, and deliver a prescribed course of radiation.

Goal 2:

Students will have effective verbal and written communication skills.

Student Learning Outcomes: Students will practice effective communication skills in the clinical setting Students will practice verbal communication skills in through class presentations Students will demonstrate written communication skills through class paper Goal 3:

Students will develop professionalism, ethical behaviors and pursue life-long learning

Student Learning Outcomes: Students will demonstrate professional and ethical values Goal 4:

Students will demonstrate problem solving and critical thinking skills.

Student Learning Outcomes: Students will demonstrate critical thinking through research and presentation of case studies Students will demonstrate problem solving skills utilizing VERT Students will demonstrate problem solving skills after completing calculations

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Admission and Retention Requirements: Safety and Technical Skills Candidates seeking enrollment into the Radiation Therapy Program must meet the safety and technical skills in the following areas: observation-communication, motor, and behavioral-social attributes.

OBSERVATION-COMMUNICATION

The student must possess the ability to communicate effectively and read, write, and use the English language. In addition, the student must have the functional use of the senses of vision, touch, hearing, and smell which are essential in assisting patients, gathering data, and maintaining their safety. Examples of observation-communication include but are not limited to: • appraise and report, within the Scope of Practice for Radiation Therapists, the clinical progress of the patient undergoing radiation therapy; • accurately interpret data from medical records and treatment plan; and • demonstrate professional attitudes in the work environment (e.g., cooperation, teamwork, attendance, and punctuality).

SENSORY/MOTOR

The student is required to perform gross and fine motor movements, maintain consciousness and equilibrium, and possess the physical strength and stamina which are necessary to provide safe delivery of radiation treatments. Examples of sensory/motor skills include but are not limited to: • transferring patients; • responding rapidly to emergency situations (cardiac arrest, respiratory arrest, falls); • protect and remove patients from an area in the event of a fire or disaster; • utilize a keyboard to input data; • distinguish equipment and background sounds and hear a variety of pitches; • see in dim light; • visually monitor patients via video monitors; • monitor patients via audio monitors; • read and apply appropriate instructions in patient charts, notes, and records; • lift 30 pounds of weight from the floor to shoulder height; • push a patient in a standard wheelchair; • have good strength in both upper extremities; and • use good body mechanics to bend, stretch, reach, stoop, kneel, and twist in performance of job duties.

BEHAVIORAL-SOCIAL ATTRIBUTES

The student must possess emotional stability and flexibility, which will enable him/her to develop the ability to function effectively in stressful situations. This includes the ability to adapt to changing environments, exercise sound judgment, complete assessment and intervention activities and develop sensitive interpersonal relationship with patients, families

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and other responsible for health care. Examples of these behavioral and social attributes include but are not limited to: • ability to think and act rationally during a crisis; • demonstrate appropriate behavior towards staff, peers, and patients according to societal norms; and • apply principles of confidentiality of medical records and HIPPA regulations.

UNSAFE PRACTICE

Unsatisfactory clinical practice is defined as a failure to perform up to the minimum standards established for the specific clinical experience. Unsafe or unethical clinical practice is defined as behavior observed by or reported to faculty that is actually or potentially detrimental to the patient, the patient's family and/or to the health care facility and staff. Every student in the program is expected to act in a safe and ethical manner consistent with the ARRT Code of Ethics ARRT Ethics Requirements for all Radiologic Technology Medical Fields

STUDENT WORK AND EMPLOYMENT

The Program curriculum is fast-paced and rigorous, and successful completion requires the full attention of students. a) Students are strongly discouraged from working while enrolled in the Program. b) The Program reserves the option to require students on academic probation to give up their employment as a condition of continuing in the Program. c) Students are prohibited from working for the Program while enrolled in the Program.

STUDENT COMMUNICATION

In almost all instances, students will be contacted by the Program via email. Students are required to view and respond to their email on a daily basis. A member of the faculty or staff should be notified immediately if a student is not able to communicate using email.

Program meets regularly with enrolled students on a quarterly basis when radiation badge reports results are shared or sooner if necessary. During this conference, students are advised on current grades, program progress and counseling on adverse grades or behaviors.

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Radiation Therapy Technology Program General Information Degree: Associate in Applied Science Hegis #: 5207 Curriculum Code: 0669 Duration of Program: 24 months, full time Start date: FALL of each year Nature of Program The program in Radiation Therapy is designed to incorporate didactic learning and clinical experiences required to produce a qualified health care professional, the Radiation Therapist.

The program is sequential in nature; students must complete an entire semester, clinical and didactic, before they are able to proceed to the next semester. Certain non-core courses may be taken at other times, then the semester in which they are scheduled to be completed, with previous permission.

Program Graduates will have demonstrated competencies in the following: 1.

Demonstrate professional, proficient communication and ethical interaction with patients and health-care providers

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Demonstrate the ability to effectively manage patient and medical information

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Demonstrate an understanding and appropriate safe use of radiation physics, equipment, and quality assurance as it pertains to radiation therapy

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Demonstrate comprehension of biological and tissue tolerances in reference to proper radiation protection

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Demonstrate an understanding of didactic concepts related to treatment sites and tumors including but not restricted to radiation therapy treatment

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Localize treatment of volumes utilizing appropriate equipment and procedures

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Accurately calculate treatment doses and prescriptions

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Demonstrate knowledge of effective radiation treatment options and application of treatment plan

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Radiation Therapy Technology Curriculum Graduation Requirements First Year First Semester (Fall)

Second Semester (Spring)

RA 100 Radiotherapy Tech I RA 101 Lab/Clinical PH 210 Radiologic Physics I BI 150 Anatomy & Physiology BI 151 Lab for BI150 EN 100 Composition-Rhetorical Strategies

RA 102 Lab/Clinical II RA 120 Radiotherapy Tech II PH 215 Radiologic Physics II BI 152 Anatomy & Physiology II BI 153 Lab for BI152

Summer Semester-1st Year RA 150 Summer Clinical I Second Year Third Semester (Fall)

Fourth Semester (Spring)

RA 203 Lab/Clinical III RA 230 Radiotherapy Tech III PH 220 Adv. Radiation Physics BI 180 Radiation Biology PS 100 General Psychology

RA 204 RA 240 PH 225 BI 241 PA 250

Lab/Clinical IV Radiotherapy Tech IV Adv. Radiation Physics II Applied Physiology Legal Issues in Health Care

Summer Semester-2nd Year RA250 Summer Clinical II Certification in Cardiopulmonary Resuscitation is required for graduation. A C.P.R Certification Course is offered by the College on an alternating summer basis for the Radiation Therapy program students.

All program coursework listed including clinical courses above must be completed with satisfactory grade of “C” or better.

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SUNY Erie Community College – City Campus Academic Standards and Policies Standards for academic progress and college policies are described in the SUNY Erie Community College Catalog and in the Student Handbook. The Radiation Therapy Technology option maintains additional policies described in this handbook.

POLICIES NOT COVERED IN THIS HANDBOOK CAN BE REFERENCED IN THE COLLEGE CATALOG

COURSE SYLLABUS

Each Radiation Therapy and co-requisite Radiation Therapy course has syllabi which describes course policies, standards, requirements, objectives, grading, etc. A course syllabus is presented to the student during the first week of classes. Copies of course syllabi are kept in the Academic Dean’s Office and in the Program Director’s Office.

ATTENDANCE POLICY FOR CLASS

Remote lecture or seated class attendance is taken within the first five (5) minutes of class.

Students arriving to class five (5) or more minutes late or leaving five (5) or more minutes early from class will be considered absent unless previous arrangements have been made with the instructor.

Students reaching the maximum allowable absences of four (4) in any Radiation Therapy or corequisite course, or two (2) in any lab/clinical course or failing to complete expected clinical hours for that semester, will also be put on probation. During the course of the program, occurrence of two (2) attendance probations will lead to termination. Extenuating circumstances may be considered. ** See Punctuality Policy below** Any student exceeding the maximum allowable absences for class or for clinical, will receive an “F” as a final grade.

For any absence to be considered an “excused medical absence”, a valid medical excuse must be provided by a physician/hospital where you were treated and state that you were/are not able to attend school/clinic etc., in the event of more than 3 medical excuses in a 12-month period, it is the program’s discretion to dismiss the student or determine if medical leave could be used.

A note stating that a student was “seen in the office” will not be accepted as an “excused medical absence” but considered a routine appointment. Excessive absences may result in having to make up clinical time over recesses if a clinical site opening is available and has been arranged through the program director and the clinical site. Program dismissal may result depending on circumstances.

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ATTENDANCE POLICY FOR CLINICAL HOURS

The Radiation Therapy Department has established the following clinical attendance policy. This policy is designed to ensure that each student accrues a minimum of 1,800 clinical hours at the time of program completion and maintains appropriate clinical attendance in their progression through the program. No student will be permitted to exceed 40 clinical hours in a week or 10 hours a day during the hours of operation Monday through Friday 5:00 AM-7:00 PM per JRCERT. Student request for clinical placements is not allowed.

In case of an absence, the student must notify the clinic an hour before the start of their clinical shift. Students must also notify BOTH clinical coordinator and the program director (text and email) within that time- frame.

• Failure to call or email Clinical coordinator and program director will result in warning • A second failure to call in to the clinical coordinator and program direct will result in a second warning • A third failure to call the Clinical coordinator and program director will result in probation No more than one (1) absence will be allowed per assigned clinical rotation, without medical excuse.

Students may be excluded from clinical lab experiences when in the judgment of the college they are unable to provide safe patient care or equipment operation care or have demonstrated unprofessional behavior which may result in course failure.

A student may be placed on probation or dismissed from school if they do not satisfy the requirements of clinical performance necessary for the safe practice of radiation therapy or fails to exhibit reasonable professional development and behavior regardless of their numerical scholastic standing. The evaluations of the student's professional development and behavior are considered to be part of the academic process.

Students banned from a clinical setting or affiliated practices may be removed from the program depending on reasons cited. This is at the discretion of the program director.

The program is sequential in nature; students must complete an entire semester, clinical and didactic, before they are able to proceed to the next semester. A student will not be permitted to advance clinically if they have not completed the program core courses for that semester.

Student are advised that this policy will be strictly enforced. Students failing to adhere to the letter and intent of this policy will be terminated from the Radiation Therapy program. The policy supersedes any previous or existing policies set by SUNY Erie Community College for the Radiation Therapy Technology program.

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Clinical time accrual is ascertained by the hours identified only on the original attendance reports submitted. A minimum number of clinical hours are required per session and per course and are identified below: Session/Course Hours Required RA101 240 RA102 240 RA150 360 RA203 300 RA204 300 RA250 360 Total 1,800 For the clinical courses, the hours listed are required for course completion and the issuance of a grade. The hours listed must be completed before a student will be permitted to accrue hours in the following clinical course. A grade of “F” will be issued for clinical hours to any student who has accrued an hour’s deficit of greater than 5% regardless of when the deficit was accrued. Also, there will be no “banking” of clinical hours. i.e., students are not permitted to apply extra hours earned in one clinical course or session toward the hours’ requirement in a future clinical course or session.

Attendance at a conference approved by the program director will count toward clinical time upon receipt of conference registration and/or receipt, valid forms that may be used for verification. Verification of attendance is required for clinic time.

Note: The Radiation Therapy Technology Department operates within the constraints of the Academic Calendar, which is established by the College’s Board of Trustees. These constraints require some adjustment to the hours listed for individual courses, but the total hours will be the same.

GUIDELINES FOR COMPLETION OF THE CLINICAL EVALUATION AND ATTENDANCE REPORTS • • •

The responsibility for the completion and approval of the clinical evaluations and attendance reports is the STUDENT’s.

Attendance reports serve as the report of the student’s attendance in the clinic Attendance is ascertained by a careful review of the attendance reports SUBMITTED (students are reminded of the strict attendance policy for clinical hours)

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TRAJECSYS

The Trajecsys Report System has been implemented into our Radiation Therapy Program for the purpose of clinical tracking. The website can be found at https://www.trajecsys.com. This system is an electronic based program that contains the student’s competency forms, evaluation forms and attendance records to provide program officials with a method by which to regulate student attendance as they rotate through their various clinical and didactic assignments.

Each enrolled student will be required to pay a non-refundable one-time fee of $150.00 for usage of this system during the 24 months of the program. Fees are subject to change without notice.

All users must first register in the system by selecting the “Registration” link on the web pages above and completing the required information. Once this has been entered, the program director will add each registrant to the system. Following this step, complete access will be granted. Orientation for this system will be completed prior to attending clinic during the first semester. Students have 30 days to complete payment following registration; if payment is not completed, access to the system will be denied. Access denial for non-payment does not excuse students from completing clinical requirements and professional responsibility deductions for failure to meet a clinical deadline will apply.

Policy Students are required to document their attendance by clocking in and out on the TRAJECSYS. In order to document clinical attendance, students have a 15-minute window for clinical clocking’s. Students are permitted to clock in 10 minutes before the clinical start time at that facility and up to 5 minutes after the scheduled clinic start time. Students arriving later than the 5-minute window are considered tardy (policy below) unless previous arrangements have been made with the instructor. This policy also supersedes any previous or exiting policy set by SUNY ERIE City Campus concerning attendance.

A detailed description of the students’ attendance is available at any time by logging into the TRAJECSYS system. The attendance log documents month, day, and year. At graduation, a copy of the clock hours for each student is placed into the student’s permanent file located in the Program Director’s Office.

This is the start of your professional development and should be treated as reporting to a job.

Accurate evaluation and interpretation of student attendance can only be accomplished if students are methodical and precise in their clocking procedures. For this reason, the following guidelines have been established and will be strictly enforced: 1. Upon reporting to the clinic for their assigned shift, students will clock-in on the TRAJECSYS system. All student clocking transactions must take place using their personal smart phone or on a computer located within the assigned clinical sites which

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is verified through an “approved IP or GPS address”. If the student uses their smart phone, GPS must be enabled so that the geographical location is recognized. If GPS is not enabled on the smart phone, then the student is advised to log in from a PC. Each student must clock in and out with their own username and password. Students are not permitted to clock in and out for each other. Students are issued ID usernames and passwords for clocking procedures. Any student found guilty of clocking in or out for another student, or having anyone else do so for them, will be considered to have plagiarized and will be subject to disciplinary action or program dismissal. Arriving to clinic at the last minute to find that a computer is unavailable due to another person using it does not constitute “internet availability” in the event of TRAJECSYS system failure or internet unavailability; you will immediately contact the program director with the clocking time and clinical site.

2. Students that fail to clock in will be counted absent until they manually enter a time exception for any missed time entries. The student is responsible for manually entering the missed arrival or departure time. Additionally, the student is responsible for asking their clinical supervisor to approve the manual entry.

3. Upon leaving the clinical site after their assigned shift, students will clock out on the TRAJECSYS system.

4. If a student consistently fails to properly utilize the time clock system this will influence their clinical grade as stated on the syllabus. Further disregard will result in disciplinary action.

Students are instructed to remind the supervising therapist to approve time clocking and time exceptions. An automated e-mail reminder will be sent from Trajecsys to the clinical supervisor at that facility reminding them after 3 days that there are outstanding clockings to be reviewed.

Any error or correction (time exception) to the attendance report must also be approved by the individual’s involved before submitting through Trajecsys.

Submission of the clinical evaluations is the student’s responsibility. It is to be completed within Trajecsys by the therapist on or before the last day of that rotation. Students have access through the reporting mechanism in Trajecsys to see if their evaluations have been submitted. Students will need to sign off in the “Comment” section of the evaluation in a timely manner.

Students may also add their comments to the evaluation at that point.

Punctuality Each student is required to be at the clinical area at the assigned time, ready to perform their educational assignments. A student who enters the clinic late or who fails to return on time from lunch or scheduled breaks may be sent home at the discretion of the clinical supervisor or

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clinical coordinator. A student sent home for the above reason will be required to make up a full clinical day. **Three (3) instances of clocking in outside of allotted times discussed under Attendance Policy equals an absence (1) for that semester. Each additional accumulation of 3 tardies will equate to an additional absence. Trends or excessive tardiness throughout the duration of the program is cause for dismissal from the Program depending on circumstances.

Probation/Termination Policy Students will be placed on probation for academic performance of below the grade of “C” in any but including all Radiation Therapy and co-requisite Science courses.

Behavioral Probation Certain policies and procedures outlined in this document, including but not limited to policies regarding attendance, classroom behavior and timeliness in submitting assignments, are designed to enhance the education and the educational process of the students in the SUNY Erie Community College Radiation Therapy Program.

The behavior of a student found to be consistently in violation of such policies and procedures may be placed on behavioral probation if a pattern of behavior exists which demonstrates willful neglect of the Program’s policies and procedures. At a minimum, behavioral probation will require that a student maintain compliance with all policies and procedures of the Program for the remainder of the time they are a student in the Program. Additional requirements may be imposed to compensate for previous violations.

A student who commits additional infractions of policies and procedures or who fails to satisfactorily complete the requirements imposed on them by the department within the prescribed time frame will be subject to dismissal.

Unsatisfactory or unethical clinical performance will also lead to probationary status or possible dismissal.

Classroom Behavior: The virtual or seated classroom is a safe environment for the student. The focus will be on learning. Causing disruptions, harassment of other students, foul language, disrespect for others, or entertaining at someone else’s expense will not be tolerated.

If virtual classroom, student’s camera will remain on for attendance purposes and audio on mute unless participation is requested by instructor. Instructor will maintain control of lecture content at all times (screen sharing option) unless permission is allowed.

Remote Proctoring- Virtual testing will be proctored using Proctorio. This software requires camera and audio on for duration of test. Examination time allotted, will be increased by an increment of 5 minutes over normal class time following vendor recommendation to allow for proctoring set up. Those with a documented IEP on file with the department will be allotted more testing time. Students will be required to thoroughly scan testing surrounding before exam is initiated. All exams are recorded and will be reviewed for any inconsistencies. Noted 19

inconsistencies may impact final test grade, issuance of probation or program termination if upon investigation plagiarism is indicated.

Students with personal computer issues can be accommodated on campus for testing but program must be made aware one day prior to test date so that program can accommodate the student on campus for testing.

Students will the terminated from the Radiation Therapy program if while on probation their academic or clinical performance falls below the grade of “C” in any course. If while on any type of probation a behavioral incident noted in class or clinic may also lead to program dismissal based on the nature and vice versa. The status of probation will remain effective throughout the duration of the program.

Students who receive a failing grade in any Radiation Therapy or co-requisite Science course will be terminated from the Radiation Therapy Program.

Students found falsifying attendance records, or any other program document will be subject to immediate dismissal.

If the program is informed by a clinical facility that a student is no longer welcome and is not to return in the future, the student will be notified immediately, and it will be at the Department discretion as to whether the student is dismissed from the program.

The possibility of future re-admittance will not be extended to the dismissed student.

Holidays, No Class and Snow Days The Radiation Therapy Technology Program normally follows the College’s schedule of holidays.

RA150 and RA250 Summer Clinical is one continuous term without break.

Students cannot be in clinic if the CITY CAMPUS location is closed due to inclement weather.

The College is open for classes; however, the area of the clinical site could have inclement weather. Driving bans issued in your hometown or that of the destined clinic site will be excused. For example, there is no snow in Buffalo and the College is open, however there are 12 inches of snow in Rochester. We cannot issue a rule regarding the above situation.

However, we urge all students to assess the situation and follow the principle of Safety first.

You must notify the clinical coordinator and program director as stated previously and report to campus that day.

Question: College is open but there is a lot of snow at the clinical site so I did not go to clinic because of driving conditions – will I need to make up the day?

Answer: This will be decided on an individual basis by the clinical coordinator and program director.

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Bereavement Policy The Radiation Therapy Technology Department will allow up to three (3) excused days for bereavement to any student experiencing the death of a spouse, parent, child, or sibling. One day will be allocated for other family members and additional time off will be taken into consideration. A copy of the obituary notice must be submitted to the department.

Student Emergencies In the event that a student becomes sick or is involved in an incident where the clinical site or school determines they need to seek medical advice from a professional, the clinical site will call the emergency contact(s) listed on the student health form to have the student picked up and transported to be seen.

Departmental policies are to be followed at all times in the clinical sites. These policies are written to protect the safety of patients and employees. In the event a student is injured while in a clinical setting, the student should observe the following procedures: 1. Notify supervising technologist of the injury, and of the circumstances under which the injury occurred. Also report the injury to the Clinical Coordinator & the Program Director verbally as soon as possible and in written form.

2. Complete a departmental incident report form for the clinical site in which you are assigned, give a copy of the report to the Clinical Coordinator & the Program Director, and keep a copy for your records.

3. If medical attention is required, go to the closest Urgent Care or emergency room if applicable Where you are assigned for clinical. The student is responsible for all costs incurred during the visit. (It may be helpful to take a copy of your insurance information with you.)

4. "NEEDLE STICKS ARE NEVER MINOR. These must be brought to the attention of your supervising technologist immediately, and an emergency room visit must be made within 24 hours of the injury. Do NOT dismiss a needle stick as unimportant; prompt action should be taken."

5. In the event a student must leave the clinical site to see a physician for health reasons and plans on returning to the clinical site the same day, they must return accompanied by a physician’s note.

Moral Character The American Registry of Radiologic Technology has established rules and regulations for Certification and Registration. These rules and regulations include qualifications for

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Certification which requires that applicants for Certification must “be of good moral character and must not engage in conduct that is inconsistent with the ARRT Rules of Ethics…”

Graduates of the program will be eligible to sit for the national certification examination for radiation therapy technologists administered by The American Registry of Radiologic Technologists (ARRT). In addition, some states require licensure in order to practice; however, state licenses are usually based on the results of the ARRT Registry Examination. Note that a felony conviction may affect a graduate's ability to sit for the ARRT Registry examination or attain state licensure.

Demonstrate behavior consistent with the acceptable professional conduct standards, such as: appearance, quality of work, quantity of work, continuing education, human relation skills, leadership skills, reading skills, writing and verbal and non-verbal communication skills.

Guidelines for Online Social Networking Social networking sites are changing the way we work and interact with others. Social networking can help you build stronger relationships with others, both on a personal level and a professional level. However, it also provides a potential avenue for lapses in professionalism and professional behavior. As a healthcare professional, you need to carefully scrutinize the way you present yourself to the world at large via social media, including your personal profiles.

Social sites may give you the impression of privacy, but you need to consider all postings and other data such as photos and video to be in the public realm and therefore potentially visible to everyone online. a) Professionalism • Postings on social network sites are subject to the same professionalism standards as any other personal interactions. The permanence and written nature of these postings make them even more subject to scrutiny than most other forms of communication.

Students may be subject to disciplinary actions within the school for comments that are either unprofessional or violate patient privacy.

• Think before you write! Everything you write online should be considered as permanent – there is no undo online. You may be able to delete a post or comment, but it is usually archived somewhere online and therefore accessible in the future. If you would be embarrassed if the Dean, Program Director, faculty, or patients read your statements, then don’t post them.

• Statements made by you within online networks will be treated as if you verbally made the statement in a public place.

• Use good judgment and avoid criticizing your school, faculty, and fellow students online.

• Do not violate copyrighted or trademarked materials. If you post content, including photos, video, or other media, you are acknowledging that you own or have the right to use these items.

• In online social networks, the lines between public and private, personal, and professional are blurred. Just by identifying yourself as a SUNY Erie RT (T) student, you are creating perceptions about SUNY Erie Community College by those who have access

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• •

• •

•

to your social network profile or blog. Be sure that all content associated with you is consistent with your role as an RT student and with SUNY Erie’s values and professional standards.

The use of social networking sites or blogs can have legal ramifications. Comments made that portray you or a colleague in an unprofessional manner can be used in court or other disciplinary proceedings Pick your “friends” carefully. Unprofessional postings by others on your page reflect very poorly on you. Monitor others’ postings on your profile and work to ensure that the content would not be viewed as unprofessional. Delete questionable or unprofessional content immediately. Consider having two profiles on social networking sites – a personal one for family and friends and a professional one for fellow students and other colleagues. However, you still need to maintain professional content on your personal profile since others could possibly obtain access via a third-party friend request or other methods.

If fellow students make unprofessional or potentially offensive comments online, you are encouraged to alert them so they can avoid future indiscretions. It may not be readily apparent to them that their comments are out of line.

Keep in mind that statements and photos posted within these sites are potentially viewable by future employers, and even if deleted can be recovered under certain circumstances. Be aware too, that images can be downloaded by and forwarded to others. It is not uncommon for potential employers to search for the social network profiles of potential hires.

Cyber stalking, sexting, requests from those who supervise or teach you to engage in activities outside of class, and other inappropriate postings to social networking sites can all be considered forms of sexual harassment.

b) Privacy Due to continuous changes in social networking sites, closely monitor the privacy settings of your social network accounts to optimize your privacy and security: • Strongly consider setting your privacy profile so that only those people whom you provide access can see your personal information and photos.

• Avoid sharing identification numbers on your personal profile such as address, phone numbers, social security number, passport numbers, driver’s license numbers, birth date, or any data that can be used to obtain your personal records and/or steal your identity.

• Others may post photos of you and ‘tag’ you in each of the photos. It is your responsibility to make sure that these photos are appropriate and are not embarrassing or professionally compromising. It is wise to ‘untag’ yourself from any photos as a general rule.

• Maintain the privacy of fellow students, faculty, health care providers and other SUNY Erie community college employees when referring to them in a professional capacity unless they have given their permission for their name or likeness to be used.

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c) Confidentiality in Social Media Context • Regardless of whether you are posting items for SUNY Erie community college business purposes or personal use, you are never permitted to post patient information.

Plagiarism and Cheating Radiation therapy students are responsible for conducting themselves in a professional manner at all times. The Program maintains that above all, ethical conduct, especially honesty, is one of the most important attributes of a competent health care professional. Having adopted the high ethical standards of the radiation therapy profession, the student is charged with the responsibility for the behavior of colleagues as well as their own.

The Radiation Therapy Technology Department will not tolerate dishonesty such as plagiarism or cheating. An infraction of the Student Code of Conduct by a student may lead to suspension or dismissal from the Radiation Therapy Technology Program. Plagiarism is the act of using or stealing (the ideas, thoughts, works or writings of another) as one’s own. This includes the use of any materials from the internet without correctly documenting references.

Advisory Council A Program Advisory Council and its work provides evidence to external agencies and the public that academic programs meet needs which are appropriate to the community college mission.

The Radiation Therapy Technology Advisory Council is composed of representatives from the college administration, clinical affiliates, faculty, and private sector.

Representatives are asked to serve for a three-year term. The Council will elect a chair from its membership to serve during this period.

Pregnancy Policy Should a female student become pregnant, it will be her option whether or not to disclose this information to program officials.

If the woman chooses to voluntarily disclose her pregnancy to program officials, it must be in writing (Form P-1). Once signed, counseling will then be provided and will include a review of the student’s radiation exposure history.

A pregnant student should know that the clinical experience is physically demanding and could possibly have adverse effects on both the pregnant student and the fetus.

The student will be advised that she will be issued an additional fetal badge and will be given appropriate counseling. Student will be provided appropriate reading material and resources to demonstrate any additional risk association with clinical rotations and assignments during pregnancy.

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The student will be asked to sign a statement (shown below) acknowledging that the counseling session and the reading materials were provided. If the student wishes to continue her clinical assignments without modification, she must provide an updated physical by a qualified physician verifying good health and making a recommendation for the student to continue in the clinical education portion of the program.

If the student chooses to temporarily withdraw from the clinical education courses, it will only be for the remainder of the semester, in which the declaration is made.

All clinical time must be made up before progressing to the next semester. As outlined in, Attendance Policy for Clinical Hours, if the declared student chooses to withdraw temporarily or entirely from the Program, re-admission may occur after completion of the pregnancy and after verification of good health by a qualified physician. She may return the following year, at approximately the same time, to complete the Program, providing that the Program is not over its maximum number of students and student is in good standing at the time of withdrawal.

The student must make her intentions to re-enroll known, in writing, at the time of withdrawal.

Arrangement will be made, on an individual basis, for the student to be re-admitted to the program within a reasonable amount of time, not to exceed the next twelve-month period.

The student also has the option at any time to submit a written withdrawal of declaration of pregnancy by completing Form P-2.

For additional information on the fetal effects of radiation students may read: Bushong’s radiographic physics book on pages 543-548 and pages 559-565 (Bushong, SC (2004)).

Radiologic science for technologists: Physics, biology, & protection, 8th ed. St. Louis, MO: Elsevier Science/Mosby, Inc.

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ACKNOWLEDGEMENT OF PREGNANCY COUNSELING I, ___________________________________________________, do acknowledge that I have received counseling from __________________________________________ regarding my clinical responsibilities during my pregnancy.

Copies of the reading materials listed below have been made available to me. I further understand that, although I have been assigned a second radiation monitor, it is simply an added precaution and does not in any way convey that any assignment in this educational program is especially hazardous during pregnancy: 1.

2.

3.

USNRC, 20, 1208 Dose equivalent to an embryo/fetus NRC Regulatory Guide 8.13 (Instruction concerning prenatal radiation exposure) Limitation of Exposure to Ionizing Radiation, NCRP Report No. 116

______________________________ Student

______________________________ Program Director

Date: ______________

Date:____________

(Disclosure and Declaration Withdrawal Forms (Pages 33-34)

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Special Lectures Attendance at all “special lectures” held off campus is required. These lectures are provided for our benefit by professionals in the field and are usually held late in the clinical day. Absence due to illness must be documented.

Parking, Transportation and Housing The college provides no transportation, parking, or housing to and at the clinical sites. The program utilizes many clinical affiliates throughout Western New York, Jamestown, and Rochester. These costs are the responsibility of the student.

Misc. Fees Additional fee requirements may include professional membership/licensing fees: American Society of Radiologic Technologists (ASRT), NYS Dept. of Health (NYSDOH) and the ARRT, Registry review courses and others are required.

Confidentiality Students must respect all “privileged information” gained by their participation in the clinical rotations. All patient information is confidential. The student may be requested to sign a confidentiality form at certain clinical facilities.

Name Tags New York State Department of Health requires that students attending schools of Radiologic Technology/Radiation Therapy wear name tags at all times while in clinic. The name tags should be in the following format: student name, college, identification as Student Radiation Therapist; in lieu of name tag, the student will wear a lab jacket/coat with the above monogrammed in black on the front.

Radiation Badges and Reports It is the policy of the program and all clinical affiliates to adhere to both State and Federal regulations regarding the use of personnel monitoring devices (badges) by students occupationally exposed to ionizing radiation.

Students are required to wear a radiation monitoring badge at all times while in clinical rotation. Failure to have a badge warrants dismissal for that day, which is considered a clinical absence. Do NOT store badges in treatment rooms or expose to direct sunlight. Students are responsible for the timeliness of the exchange. If you lose your badge immediately notify the clinical coordinator or program director and a spare will be issued. A $15.00 replacement fee will be assessed for a damaged or lost badge upon time of collection.

Copies of the badge reading reports are made available to students upon request. These reports are maintained in the department office for minimum of five (5) years. Students will be

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notified immediately of any unusually high badge readings. A student exposure threshold dose of 100 mrem per quarter is established.

In the event of an accidental exposure: • The student must report the incident immediately to the clinical supervisor, clinical safety officer and clinical coordinator. The student must submit to the PD a written, detailed report including machine, date, time, etc.

• There will be an investigation and determination of the accident or excessive exposure.

• The incident will be reported and recorded per the clinical/hospital site policies.

• Radiation Safety Officer will notify the Division of Radiation Protection, if applicable.

If the dose is acquired as a non-specific incident, an investigation to determine a cause will be conducted including the status of the badge and the clinical sites involved. Written notice will be given to the student and a copy placed in their department file.

Adverse Weather Conditions In the event that classes at SUNY ERIE – City Campus are cancelled; clinical laboratory sessions will also automatically be cancelled for that day.

Health Policy Each student enrolled in the Radiation Therapy Technology Program is required to provide the Department and the College’s Health Office a completed Allied Health Report signed by a physician.

MRI Policy Each student enrolled in the Radiation Therapy Technology Program is required to complete the MRI Student Safety Screening Questionnaire and watch a mandatory MRI Power Point presentation on MRI safety.

Policy Effective April 6, 2016 Regarding MRI safety standards in the field of Radiation Therapy, the program developed an informational power point and student safety health screening form. The MRI Student Safety Screening Questionnaire is able to assess who may be at risk for injury if assisting in a clinical procedure that may involve setting up a patient for an MRI. In the event our Radiation Therapy Technology students are working in an MRI environment, the student has been made aware of the potential health and safety concerns working near the MRI magnet.

Students who have identified “YES” (with the exception of piercings which MUST be removed before/prior to entering the scan area) on the MRI Student Safety Screening Questionnaire will NOT be asked to perform the MRI procedure outside of the safe “Zone”. All clinical sites will be informed of adverse conditions and asked to excuse the student from participating in any MRI

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procedures as part of their clinical rotations. This form will be maintained in the students file in the department unless requested by clinical site procedures.

All students will be shown MRI Safety Power Point in RA101 and complete the screening form before clinical rotations start, to understand the potential dangers and patient safety when near MRI scanning room. Attendance is mandatory for the MRI Safety Power Point and attendance and questionnaire completion will be documented in Trajecsys.

Health and Accident Coverage Policy Students enrolled in the Radiation Therapy Technology Program may be required to purchase a health and accident insurance policy and must present proof of coverage in order to attend clinical rotations at affiliate institutions.

Polices, Rules and Regulations for Students in Radiation Therapy Technology During Clinical Rotations at Affiliate Locations: 1. According to the JRCERT and New York State Department of Health, students must at all times be under the direct supervision of a qualified practitioner -licensed radiation therapist, nurse assigned to their rotation and thus, responsible to him or her. This will be the policy until the student completes the clinical component of the radiation therapy program. Direct supervision is first sight line of students not through camera or other closed circuit.

2. The students will be required to report to their Supervisory Therapist at the appointed starting time each day and make their whereabouts known at all times until requesting permission to leave at the end of the day. If an unsupervised condition arises, the student is obligated to report it to the clinical supervisor and program facility immediately.

3. The students will adhere to the schedule assigned to them during their time there unless other arrangements have been made prior to the commencement date (Special situations will be considered) 4. Student is expected to use clinical time wisely. When not performing direct clinical duties student should consider the following activities: • Practice reading charts • Practice checking charts • Practice simulation or treatment set ups • Work on treatment machines when assigned to a slow SIM (ONLY if another student is NOT assigned) • Review textbooks or journals in the dept.

• Practice calculations • Work on homework 5. The students will be required to attend all conference and lectures as suggested by their Supervising Therapist and/or Program Director.

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6. The students will at no time administer any kind of patient care unless in the company of and directed by a licensed professional 7. Students must have all treatment procedures reviewed by a qualified radiation therapist. Students may perform all aspects of a patient set-up consistent with their level of achievement under direct supervision. (Under no circumstances will students perform unsupervised patient-related tasks).

8. Student begins clinical participation with observing a radiation therapist and moves from this a passive mode to assisting, based on student progression and ability to use the equipment. As a student gains experience and confidence, they can perform independently and request to perform a competency in a specific skillset always under direct supervision. This escalation of experience in various procedures will be logged daily in Trajecsys. Competency requirements for clinical must be completed prior to graduation 9. Students assume the responsibility of maintaining a daily clocking in and out as stated in the attendance policy. Clocking must be approved through Trajecsys every day or two by the supervising therapist at the time of dismissal (see Guidelines for Completion of the Clinical Evaluation and Attendance Reports) 10. Students are not allowed to leave the affiliate site during their clinical rotation practicum except during their lunch period or unless previously approved by the Program Director (Failure to comply with any of these rules may result in the termination of their clinical assignment. This decision will be at the sole discretion of the Supervising Therapist and can be effective immediately upon informing the College.)

Clinical Dress Code and Hygiene Policy All students are required to follow the dress code and exercise proper hygiene.

All student must wear a film badge and a lab coat identifying them as a SUNY ERIE Radiation Therapy student. Any student not wearing a film badge will be asked to leave the clinic and a clinical absence will be indicated.

Dress includes: All clothing and minimal jewelry to be consistent with a professional/business dress standard.

Student’s clothes should be neatly pressed for professional appearance.

Students will always wear clean and pressed Gray scrubs for uniforms along with name badge donned. The student must wear their embroidered scrub or name tag identifying them as a student along with their name.

Plain white, clean sneakers should be worn at all times. These should be worn for clinical rotations only.

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A student who reports to a clinical education center not in proper attire may be sent home at the discretion of the clinical supervisor. The student will be required to make up the lost clinical time.

During certain clinical education assignments, such as block fabrication, it is recommended that the student wear appropriate protective clothing (e.g., gloves, goggles, protective apron).

While working with patients, some procedures may require the student to use personal protective equipment (PPE) such as gloves or masks. Students are responsible for following institutional procedures where they are assigned.

Hygiene includes: The proper care of hair, fingernails, and skin.

Hair, including beards and mustaches, should be neatly groomed. Hair (shoulder length) must be tied back.

Fingernails are to be clean, trimmed and extend no farther than ¼ in. beyond the fingertips.

Clear or conservative light-colored nail polish may be worn. No acrylic nails allowed for infection control purposes.

Cosmetics: Should be conservative. No perfumes or body lotions. Students are required to control body odors which include perfumes, colognes, or body lotions. Patients receiving radiation therapy and chemotherapy may experience symptoms of nausea and aversion to strong odors. Clinical staff may also have sensitivities/allergies to perfumes and cologne.

Chewing gum is discouraged.

Jewelry: Watches, small rings, small earrings are permissible. Costume, large jewelry is not permitted. Ear stretchers are not allowed, and the opening should be covered.

No visible tattoos are allowed (nose, lip, belly etc.) Piercings are limited to ears only (one set of earrings) Noncompliance is at the discretion of the program and may result in dismissal from clinic as an unexcused absence for that day.

Smoking Policy Smoking tobacco or e products use is prohibited on all SUNY ERIE Campuses. For further information, contact your campus Dean of Students office. Students are responsible for knowing and abiding by the smoking policies set forth by each clinical site. Smoking is only permitted in designated areas and students should be mindful of not smelling like smoke when reporting to clinic.

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Ethical Expectations Students are expected to maintain a high standard of ethical behavior in the clinical education settings and in the classroom: • Students must abide by the standard rules and regulations of SUNY Erie Community College and the clinical education setting • Students must respect the patient’s right to privacy and keep confidential the information relating to the patient. Students are expected to comply with HIPAA regulations. Failure to do so can result in dismissal from the program.

When preparing case studies for classroom presentations or other reports, etc., it is mandatory that the student receive permission of the clinical supervisor to make copies of any patient-related material. Any copies of reports or films used for presentations must have the patient’s name and clinical number (or any other identifying information) covered. This helps to ensure the patients right to confidentiality.

Examples of Inappropriate Behavior Any student may be disciplined or discharged for just cause which may include, but is not limited to, the following breaches of standards for reasonable conduct: • Excessive/Chronic absenteeism or frequent tardiness • Reporting to school or clinic under the influence of intoxicants or drugs • Harassment or discrimination of employees or students (e.g., sexual, racial, cultural or age) • Refusal to accept adjustment of clinical assignment at the direction of the clinical supervisor or program director • Continued failure to follow safety regulations, gross or willful negligence in the use of radiation or the handling of radioactive substances or treatment equipment • Is, by his/her own admission, or has been found guilty of theft.

• Soliciting of gifts, gratuities, or tips; selling or soliciting in the clinic or hospital.

• Releasing or failure to prevent the release of confidential information (HIPAA regulations) • Abuse, misuse, waste or destruction of clinical site or SUNY ERIE property.

• Unauthorized operation of equipment.

• Possession of or use of weapons in the hospital or on school premises, or physical violence, threats of harm or abusive conduct.

• Personality difficulties, inability to get along with employees, other students or patients • Establishing a social relationship with a patient who is on treatment • Dating a clinical staff member or fellow student at the assigned clinic could result in the student being reassigned to a different clinical setting.

• Texting friends or family during clinical assignment

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• • •

Students in the program may be subjected to drug testing and criminal background checks at their own expense. Failure to meet clinical site requirements may preclude completion of the Radiation Therapy Program.

Felony conviction may prevent a student from completing our academic program through fieldwork, a degree requirement, required for degree completion.

Response to a criminal conviction that may affect an individual's ability to be licensed upon graduation.

Miscellaneous Professional Behaviors • • • • • • • •

Eating and drinking in the clinical area is NOT permitted.

Newspapers, magazines, and non-textbooks are NOT to be taken into the clinical area.

Students are expected to utilize any “down time” by reviewing patient records, reviewing films, or assisting other radiation therapy teams.

Students are not allowed to study for their didactic courses while at clinical unless on a designated break or approved by the radiation therapy team.

Students are not allowed to use the clinical affiliate computers for personal reasons and may only use them during the lunch hour for clinical related work after receiving permission from the staff.

All cell phones are to be turned off while in clinical and not carried in your clothing or lab coat.

You may keep your cell phone in your bag and check it during the lunch break.

You must inform the program of any address or phone number change(s).

Note: The FINAL DECISION as to the appropriateness of a student’s dress is that of the clinical instructor(s). Students may be dismissed and will need to make up clinical time at that clinical site.

Policy on Health Records and Communicable Diseases The health and safety of students, clinical staff, faculty, and patients associated with the educational activities of the program must be adequately safeguarded.

Radiation Therapy students must be compliant with the college immunization requirements.

The college reserves the right to deny progression in the Radiation Therapy Program when students have incomplete or unacceptable physical exam reports. SUNY Erie Community College and the Radiation Therapy Technology Department operate under NYS Department of Health guidelines regarding student health and communicable disease. The College requires that each student accepted into the Radiation Therapy Technology Program undergo a physical examination of sufficient scope to ensure that no student assume his/her educational duties unless he/she is free from health impairments (physical or mental) which are of potential risk to others or which might interfere with the performance of his/her duties, including habitation or addiction to depressants, stimulants, narcotics and alcohol or other drugs or substances which may alter the individual’s behavior. Students in the program may be subjected to drug testing

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and criminal background checks at their own expense. Failure to meet clinical site requirements may preclude completion of the Radiation Therapy Program.

This examination shall be required yearly and include immunizations as indicated on the SUNY Erie Community College – Allied Health Report. Students must provide evidence of updated required immunizations and a completed physical exam ensuring that they are in good physical and mental health and are capable of completing the requirements of the clinical part of the program.

All individual physical examinations will be kept in the College’s Health Office, the student file in the radiation department office and a copy will be provided to the clinical affiliates of the program. The clinical affiliates of the Radiation Therapy Technology Program have formalized communicable disease policies for employees. When students are assigned to a clinical affiliate, they will be held to the same policies set for employees of that affiliate regarding communicable disease.

Program Standards The following are JRCERT Standards for an Accredited Educational Program in Radiation Therapy which can be found posted in the classroom: Standard One: Integrity The program demonstrates integrity in the following representations to communities of interest and the public, pursuant of fair and equitable academic practices and treatment of, and respect for, students, faculty, and staff.

Standard Two: Resources The program has sufficient resources to support the quality and effectiveness of the educational process.

Standard Three: Curriculum and Academic Practices The program’s curriculum and academic practices prepare students for professional practice.

Standard Four: Health and Safety The Program’s policies and procedures promote the health, safety, and optimal use of radiation for students, patients and the general public.

Standard Five: Assessment The program develops and implements a system of planning and evaluation of student learning and program effectiveness outcomes in support of its mission Standard Six: Institutional/Programmatic Data The program follows guidelines set by JRCERT in regard to policies, procedures and STANDARDS to achieve and maintain specialized accreditation

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Accreditation and Standards Agencies: Students are advised of the following organizations involved in the establishment of program standards and accreditation for the Radiation Therapy Technology Program: State of New York Department of Health Bureau of Environmental Radiation Protection 547 River Street, Room 530 Troy, New York 12180-2216 Phone: 518-402-7580 American Registry of Radiologic Technologists 1255 Northland Drive St. Paul, Minnesota 55120-1155 Phone: 651-687-0048 www.arrt.org Joint Review Committee on Education in Radiologic Technologic (JRCERT) 20 North Wacker Drive Suite 2850 Chicago, IL 60606-3182 Phone: 312-704-5300 www.jrcert.org Competency Requirements There are clinical core competencies that all radiation therapy students must demonstrate to establish eligibility for ARRT Certification. These competency requirements became effective January 1, 2002. They were last updated in January 2016 (effective January 2017) and are in addition to successful completion from an educational program accredited by ARRT. The requirements listed are the programs minimum core clinical competencies necessary to establish eligibility for participation in the ARRT Radiation Therapy Examination. The ARRT encourages education and experience beyond these core requirements.

Students must demonstrate competency in all of the procedures. Eighteen mandatory Treatment Procedures must be demonstrated on patients. The remaining two Treatment Procedures may be demonstrated on patients or in a clinical lab environment.

Students must also participate in the following three procedures: • Total Body Irradiation (TBI) • Craniospinal • Brachytherapy

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All of the ten Simulation Procedures must be demonstrated on patients by CT simulator or treatment machine. Two additional Simulation Procedures (Skin and Endocrine) may be demonstrated on patients or in a clinical lab environment.

Students must submit pre-treatment and pre-simulation knowledge assessments before attempting a competency.

A record of the competencies completed by each student is retained in their file in the Radiation Therapy Department. Students are responsible for maintaining a copy of their individual completion record. Periodic updates of the completed competencies will be made available to the individual students.

Policy for Student Complaint and Procedure The following procedure will be applied to any and all complaints and/or allegations made against the Radiation Therapy Technology Program.

SUNY Erie Community College Student Grievance of Academic Decision Procedures for Student Grievance of Academic Decisions Students who perceive that their rights were violated through an inappropriate interpretation, application or enforcement of a policy must engage in the informal grievance process before engaging in the formal grievance process. Title IX complaints are not subject to this requirement and must be documented and then submitted to the Office of Equity and Diversity according to the Title IX procedure. Employees of SUNY Erie are obligated to report any knowledge of complaints that are perceived to be discriminatory based on race, ethnicity or gender, harassing, disability or sexually violent as these complaints are Title IX and should be immediately referred to the Office of Equity and Diversity. For an expanded definitions and or the procedure to inform or file a Title IX complaint visit https://www.SUNY Erie.edu/equity-diversity All faculty and staff of SUNY Erie must document knowledge of student complaints for reporting purposes and to provide background if the grievance escalates. This includes logging of Title IX complaints. Additionally, SUNY Erie has an obligation under federal law 34 CFR 602.16(a)(1)(ix) to track student complaints to maintain quality of service.

The Procedures for Student Grievance of Academic Decisions offer both complainant and respondent the opportunity for mediation and resolution by following a systematic process.

Informal Grievance Process: 1. The first step in the Informal Grievance Process involving complaints related to a grade on a (test, paper, quiz, exam, or another assignment) requires the student to first attempt resolution with the instructor of the course. If the concern pertains to a grade received in a course, the request for review must be made no later than three weeks after the final grade for the course is submitted.

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2. If a resolution is not reached with the instructor, the student must next attempt resolution with the Department Chair or Head of the department involved.

3. If a resolution cannot be reached with the Department Chair or Head, the student may then contact the Dean of Academics over the department, or Vice Provost if a Health Sciences program, to consider the student's request and attempt to negotiate an equitable resolution between the student and instructor.

4. At this point, if the student is not satisfied with the resolution, the student may then file a formal grievance that will be presented to a committee for adjudication. The steps of the formal grievance process are below. All faculty and staff that are informed of the students’ complaint during the informal complaint process are required to log the complaint in compliance with SUNY Erie, State University of New York (SUNY), New York State Education and Federal requirements. The record of the complaint must identify the student, the nature of the complaint and individuals involved, the individual reporting the complaint, and the steps used to resolve the complaint. The complaints can be tracked on the SUNY Erie Academic Affairs Online Praise, Complaint – Log of Submissions.

Formal Grievance Process: The Formal Grievance Process is invoked when a student is unable to achieve resolution through the Informal Grievance Process.

1. Students who wish to progress into the Formal Grievance Procedure must submit their grievance and their recollection of all interactions during the Informal Grievance Process to the Dean of Academics or Vice Provost over the department that was involved in the Informal Grievance Process. The Dean of Academics or Vice Provost must record the escalation of the grievance. The escalation can be documented with the SUNY Erie Academic Affairs Online Praise, Complaint, Suggestion - Log of Submissions.

2. Students may opt to involve another staff or faculty member as a Staff Advocate to advocate on their behalf and to help them navigate as the issue is investigated with the goal of achieving a fair and equitable outcome. The Dean of Students’ office can be contacted for more information on the role of Student Advocates.

3. The student’s grievance will be reviewed by the Adjudicating Committee. The committee will be convened when the Dean of Academics notifies the Provost’s office of the formal grievance.

4. The Adjudicating Committee will be comprised of members of the academic team, representatives of Student Affairs and faculty members, minimally. At least one member of this adjudicating body will be trained on SUNY policies, educational law, and the adjudication process.

5. The Adjudicating Committee will review the grievance and any accompanying documentation submitted from the faculty member(s) involved in the grievance, the complainant, and any witnesses. The Adjudicating Committee may question any of the parties involved in the process.

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6. The Adjudicating Committee’s written recommendation will be submitted to the Provost and Executive Vice President who oversees Academic Affairs and Student Services. The Adjudicating Committee will address any questions of the Provost and the Provost will provide a written decision to all persons involved. The final decision rests with the Provost. New information is the only factor that can be considered for revisiting the case.

7. The official decision will be sent within thirty days to the student via email, certified mail return receipt and regular mail and the Provost’s decision will be final unless new evidence, or a new information that would impact the decision is presented. Student should maintain current contact information at the college.

8. Notification of a request to reexamine a case based on new evidence must be submitted in writing to the Office of the Provost. The Provost will notify the student within 30 days of receipt of request as to how to proceed.

9. The adjudication committee and the Provost’s decision are required to log the complaint in compliance with SUNY Erie, the State University of New York (SUNY), New York State Education and Federal requirements.

Student Grievance of Academic Decisions Policy

Academic Matters: Grading Concerns In specific instances when a disagreement arises between a faculty member and a student over matters of academics and or grades pertaining to a course, the student's complaint should be reviewed first by the Department Chair or Head and then, if needed, may be reviewed by the Dean of Academics or Vice Provost of Health Sciences to determine if a change in status is warranted.

Other circumstances that impact the relationship between a faculty member and a student enrolled in a course may also arise, such as academic dishonesty, matters of course attendance, professionalism, or safety concerns in clinic, grading of an individual assignment (e.g., test, paper, project, mid-term, or final exam) and adherence to accreditation issues.

Ideally, such matters should be dealt with between the faculty member and the student, except in case of an allegation of academic dishonesty with the potential consequence of disciplinary suspension and or dismissal. In this instance, students are entitled to due process. Due process is defined as an established course or process for judicial proceedings designed to safeguard the legal rights of the student. Please see the section below on this topic.

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Academic Dishonesty and Disciplinary Dismissal: In instances of alleged violations of academic dishonesty with a potential consequence of disciplinary suspension and or dismissal, SUNY Erie follows The State University of New York (SUNY) standard and law regarding due process. Due process is defined as an established course or process for judicial proceedings designed to safeguard the legal rights of the student i.e., that includes: (1) notice of the disciplinary process; (2) notice of the charge; (3) the arrangement of a meeting or hearing; and (4) a written explanation of the decision. In addition, all decisions are subject to substantive due process review.

Faculty are encouraged to request a conference with the Dean of Students before taking any action regarding academic dishonesty in order to ensure that the student receives due process.

For the full procedure regarding academic dishonesty and disciplinary dismissal, please contact the Dean of Students.

Complaints Regarding Faculty Employees (Non-Grading Concerns): Please note that complaints regarding faculty members regarding matters other than grades cannot be pursued through the process outlined here. Student complaints concerning faculty members are subject to the grievance process outlined in the FFSUNY ERIE Bargaining Contract.

Student complaints regarding faculty members shall be made to the Department Chair or Head, the Dean of Academics, or the Vice Provost of Health Sciences.

Student Affairs Matters: Students may lodge a complaint involving matters outside of the classroom experience, involving a service or an interpretation of a policy or procedure or treatment by a staff person.

The complaint may be reviewed (by the supervisor, director, or a vice president over the area) to determine if the complainant received the optimal student experience.

Student Rights and Responsibilities: Incoming new and transfer students are informed of their rights and responsibilities and appropriate student behavior during the mandatory new student orientation program called Support Through Advisement, Registration, and Transition (START).

With the aim of addressing inappropriate student behavior, SUNY requires that all campuses confirm that students have been informed of their rights and responsibilities as an enrolled student, received a copy of the campus Student Code of Conduct and that students be made aware of guidelines for appropriate behavior and other expectations contained therein.

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Commitment to Diversity: Title IX Complaints: SUNY Erie Community College is committed to creating and fostering a learning and working environment based on open communication and mutual respect. Title IX of the Education Amendments of 1972 (“Title IX”) protects individuals from discrimination and harassment on the basis of sex or gender in any educational program or activity operated by recipients of federal aid. SUNY Erie Community College as a recipient of federal funds, complies with Title IX and 34 CFR Part 106 by prohibiting sex and gender discrimination and harassment, which includes sexual misconduct and sexual violence, in education programs, activities, employment, and admissions. If you encounter sexual harassment, sexual misconduct, sexual assault, or discrimination based on race, color, religion, age, national origin, veteran’s status, ancestry, sex, sexual orientation, gender identity or disability please contact the Office of Equity and Diversity.

The provisions of Title IX and the Americans with Disabilities Act (ADA) complaint procedure pertaining to discrimination, harassment, or disabilities concerns are designed to provide all members of the college community with a process to report incidents as well as to provide for prompt and effective resolution of any reports of such violations.

For more information on Title IX or specific complaints relative to this process, contact the Equity and Diversity Office (716) 851-1118 .

Timelines: The formal complaint procedure is set up to take no more than thirty business days once a complaint has been filed. To obtain a remedy under the Student Complaint Procedure, complainants must be a current enrolled and registered student. A complaint must be filed no more than ninety days after the incident or complaint. Complaints older than ninety days will not be heard. Matters involving grades must be filed no more than three weeks after final grades are submitted.

Advocates: Students may select their own advocate or ask for assistance in obtaining one on their behalf by contacting the Dean of Students, the Student Support Service Center, or the Student Success Center.

An advocate may assist the student with the informal or formal complaint process and or serve as a liaison during any meeting, discussion and or hearing.

Record Keeping: All records of the informal and formal complaint process, including reports and other disposition documents, are the property of the college and will be tracked by the receiving

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academic and or student office for reporting purposes. No names or demographic data will be contained in the final aggregate Student Complaint Report.

Academic Complaint Workflow Student Affairs Complaint Workflow Student Formal Complaint Procedure Radiation Therapy Department Policy on Cell Phone Use Effective December 21st, 2009, the following measures were put in place for any student who is observed using a cell phone for any purpose other than clocking in or out using Trajecsys while in class or during a clinical rotation.

The first time, the observer should give the student a verbal warning.

The second time, the observer should send the student home for the day. The incident will be reported to the Radiation Therapy Department and the entire day will be recorded as an absence.

The third time that same student is observed using a cell phone, he/she will be dismissed from clinic and the incident will again be reported to the department.

If there should ever be a fourth time, the student will be terminated from the program immediately. This policy supersedes any SUNY Erie Community College policy.

It is unacceptable for cell phone usage in the clinic or classroom. Computer usage in class outside of class related activities is a distraction to classmates and instructors and will not be tolerated.

In the event of extenuating circumstances, inform the clinical staff and abide by that clinic’s cell phone policy.

If there is a reason you might have to be contacted during class, inform the instructor before class.

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SUNY Erie Community College – City Campus Radiation Therapy Technology Division of Health Science Student Handbook Part II (See Table of Contents at beginning of Handbook) Mandatory Radiation Therapy Treatment Procedures Requirement: Candidates must demonstrate competence in 18 radiation treatment procedures. These mandatory procedures must be demonstrated on patients and reviewed with appropriate personnel. Three (3) may be demonstrated in a clinical lab environment with the approval of the program director.

Demonstration of competence does not require actual delivery of treatment dose.

Demonstration of competence includes considerations related to radiation safety, equipment operation, patient and equipment monitoring, patient positioning, treatment volume localization, dose to critical structures, image acquisition and registration (e.g., MV, kV, CBCT.), dose verification, record keeping and patient management and education.

Brain Primary Metastatic

Abdomen* IMRT and/or arc therapy Multi-field (non IMRT)

Head & Neck Multi-field

Skeletal Single field spine Multi-field spine Extremity

Thorax Multi-field (non IMRT) IMRT and/or arc therapy

Pelvis* Multi-field supine Multi-field prone

Breast Tangents only Tangents with Supraclavicular Tangents with Supraclavicular and posterior Axilla Boost Special Set up (e.g., Photon or Electron Boost, Prone, IMRT, Gating) Electron Fields Single Abutting fields These two procedures may be demonstrated on patients or in a clinical lab environment.

Skin Endocrine Primary Primary (e.g., pituitary, thyroid, adrenal)

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Multi-field includes two or more fields and may include 3D conformal, IMRT and/or arc therapy (unless specified otherwise). *Abdomen and Pelvis do not include treatments for metastatic disease.

Participatory Procedures Requirement: Candidates must participate in three (3) procedures. Participation means taking on an active role in the procedure and understanding the critical concepts vital to the success of the procedure. Participation may be performed in a clinical lab exercise if necessary.

Total Body Irradiation (TBI) Craniospinal Brachytherapy Mandatory Simulation Procedures (CT or Rx Machine) Requirement: Candidates must demonstrate competence in treatment simulation for the anatomic regions listed below. Either a CT simulator or treatment machine may be used.

The following simulation procedures must be demonstrated on patients.

Requirements specific to CT simulation appear in the appendix: Brain (2) Head and Neck Thorax Breast (2) Abdomen Pelvis (2) Skeletal Students should attempt to demonstrate competence in treatment simulation of the areas listed below either on patients or under simulated conditions: Skin Endocrine Important: Demonstration of competence includes consideration related to radiation safety, equipment operation, patient and equipment monitoring, patient positioning and marking, treatment volume locations, imaging procedures, record keeping, patient management and education.

Specific requirement for CT simulation is summarized on the reverse side of form.

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Radiologic Technology/Radiation Therapy Confidential Policy for Clinical Affiliates I, ___________________________________________________________, being a student in the Radiation Therapy Technology Program at SUNY Erie Community College – City Campus, agree to conform to the terms of the policy regarding the matter of confidentiality with regards to the clinical facility at: ________________________________ _____________________________________________________________________________, I understand and agree not to disclose any information, whether written or verbal, regarding patient information, policies, procedures, physicians, technical staff, billing and finances, unless I am specifically authorized to do so by the patient or clinical supervisor or if I feel the information is such that I should bring it to the attention of the program director.

Any information regarding the above that I come in contact with shall be considered privileged communication and remain confidential to the clinical facility.

Any significant breach of this agreement shall constitute good cause for dismissal from the Radiation Therapy Technology Program. In addition, it may subject me to liability and responsibility for any legal damages resulting from my unauthorized disclosure.

____________________________________ Student Signature

______________________________ Date

____________________________________ Chief Therapist/Supervisor

______________________________ Date

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Form P-1 SUNY Erie Community College Division of Health Sciences Radiation Therapy Technology Department Voluntary Pregnancy Disclosure Form Student Name: ________________________________ Date of Declaration: _____________ In accordance with the current program policy regulations, I, ___________________ _____________________________, wish to voluntarily declare that I am pregnant.

My expected due date is: ____________________.

My estimated date of conception was: ______________________.

In making this declaration, I wish to be afforded the protection specified under this regulation that the unborn child shall not receive in excess of 500 millirem during the pregnancy term. I am aware of the radiation programs policy on pregnancy and will abide by all of its rules and regulations. _______________________________________ Student

______________________________ Date

_______________________________________ SUNY ERIE Student ID# ________-________-________ Social Security# Acknowledgement of Receipt of Declaration: __________________________________________ ______________________________ Program Director Date __________________________________________ ______________________________ Clinical Coordinator Date Note: The original copy will remain in the student’s clinical file. The student will receive a copy.

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Form P-2 SUNY Erie Community College Division of Health Sciences Radiation Therapy Technology Department Pregnancy Declaration Withdrawal Form I, _____________________________________________________, wish to withdraw my declaration of pregnancy. I understand that the lower dose limit for the fetus is no longer applicable and that fetal monitoring will no longer be necessary or provided.

If pregnant, but formally withdrawing declaration of pregnancy, I hereby release the Radiation Therapy Program, and clinical affiliate sites, of any responsibility for fetal exposure.

_______________________________________ Student

______________________________ Date:

Acknowledgement of Receipt of Declaration:

_______________________________________ Program Director

______________________________ Date

________________________________________ Clinical Coordinator

______________________________ Date

Note: The original copy will remain in the students’ clinical file. The student will receive a copy.

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MRI Student Safety Screening Questionnaire As a Radiation Therapy student, you may be exposed to work environments that have high magnetic field strengths. It is not safe for operators to have certain medical conditions or implanted devices within their bodies. Please complete the following questionnaire: Do you have or are you…?

Cardiac pacemaker, wires or implanted cardiac defibrillator or heart valves?

Implanted Neurostimulator/Electrodes/Wires?

Heart Valve Replacement or annuloplasty ring?

Aortic Aneurysm repair?

Any type of magnetically-activated implants or devices?

Any type of implanted pumps (insulin or chemo?)

Head surgery requiring brain aneurysm clip?

Ear implant (cochlear, other?)

Eye implant (lens, retinal tacks?)

Eyelid spring or wire?

Metallic foreign body in the eye?

Any history of metal in the eye that was removed?

Tattooed eye or lip liner, body piercings (if “yes”, please indicate by circling: Piercings or Tattooed Spinal cord stimulator?

Implanted coils, filters or stents?

Penile prosthesis?

Bullets, pellets, metal fragments or shrapnel in your body?

Breast tissue expander?

Any prior surgeries with surgical staples, clips, wires, pins, or rods (prosthesis)?

Yes

No

I hereby affirm that all of the information supplied on this questionnaire is accurate and complete. I understand that some YES answers may make it unsafe for me to work in the field of MRI and prohibit me from entering the MRI scan room while in the Radiation Therapy Program.

Before entering the MRI scanning room, I have been made aware to remove ALL metallic objects including: hearing aids, dentures, partial plates, keys, pagers, call phones, eye glasses, hair pins, barrettes, jewelry, body piercing jewelry, watch, safety pins, paper clips, money clips, credit cards, bank cards, magnetic strip cards, coins, pens, pocket knife, nail clippers, tools, clothing with metal fasteners or metallic threads.

I will be under direct supervision at all times by MRI technologist or accompanying Radiation Therapist. ________________________________________________ ________________________ Radiation Therapy Student Signature Date

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Exposure A

SUNY Erie Community College – City Campus Division of Health Sciences Radiation Therapy Technology Student Radiation Exposure Form

Student: ________________________________________

Date: ___________________

In accordance with the radiation therapy program policy, I, ________________________ ____________________________________, wish to acknowledge that my personal monitoring badge received an exposure above the program’s established threshold dose of 100 mrem per quarter.

I am aware of the circumstances of this exposure and notified the clinical site RSO, clinical chief/supervisor, and program coordinator at the time of the incident.

Details: _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I am unaware of the circumstance of this exposure reading as documented by the quarterly exposure report provided by Global Dosimetry Services for the monitoring period from ________20 __ (date) through ________20 __ (date)

(see Exposure B Form)

SUNY ERIE Student ID#________________________ Social Security #______-______-______ Acknowledgement of receipt: Program Director__________________________________Date: ___________________ Clinical Coordinator_______________________________

Date: ___________________

Note: The original copy will remain in the student’s clinical file. The student will receive a copy.

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Exposure B SUNY Erie Community College – City Campus Division of Health Sciences Radiation Therapy Technology Student Radiation Exposure Form The Global Dosimetry Services Report for the monitoring period from _________20___ through _________20 ___ has been verified that student ______________________________ received an exposure of ____________________ for that quarter, exceeding the established threshold dose of 100 mrem/quarter.

Clinical affiliate sites visited during that time frame, RSO, any known exposure circumstances: 1.________________________________________

RSO__________________________

______________________________________________________________________________ 2._________________________________________

RSO__________________________

______________________________________________________________________________ 3._________________________________________

RSO__________________________

______________________________________________________________________________

An inquiry will be made with each of the above Radiation Safety Officers. Records of students from the previous rotations of these clinical sites will be reviewed.

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The Radiation Therapy Student Handbook has been reviewed in detail by the instructor. I fully understand all of the policies, especially those regarding confidentiality, program dismissal, plagiarism and pregnancy, and have been made aware of the seriousness and consequences for non-compliance. By my signature, I agree that the above statement is correct.

Student:

_____________________________________

Date: __________20 ___

_____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ Instructor: _________________________________________ Date: ___________20 ___ This signed statement becomes part of the departments permanent file and a copy will be distributed to the clinical affiliates if requested.

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